GW1--03405_Well Construction - GW1_20240610

WELL CONSTRUCTION RECORD For ltgeanal Use ONLY:
This form can be used for single or mutiple wells
14 WATER TONES w
1.Well Contractor Information: -
FROM TO DESCRIPTION
WILLIAM LAWSON 59ft. 60 ft.
Well Contractor Name 142 ft. 143 ft.
NCW C3491 A 15.OUTER CASING(for mufti-cased wens)OR LINER(if applicable)
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL -
CHEROKEE WELL DRILLING 0 t 54IL 6.125 hi' SDR 21 PVC plastic
Company Name ft. ft. in.
16.INNER CASING OR TUBING(geothermal closed loop)
F
2.Well Construction Permit#: W2024000157 t/- - K -_ - - _-- -
RO'tf TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction per-twits(ie Count 4 State,Variance,etc D. ft. I in. I
3.Well Use: ft. ft. / in. •
17.SCREEN
FRO\t 7-To DIAMETER 1 THIC}NESS SLOT SIZE iMATERI\I -,
Residential ft ft., in.
p--- -
ft. ft. in-1
b`V[,i �J Li 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
JV V j 0 424 0 fk 3 tr Bentonite Pell 50 Gravity
3 f't. 20 it Bentonite sluqy 150 Pumped/Tremie
loisfamaion PISCirrart f Ul.I f ft. _1
19.SAND/GRAVEL PACK(dabble)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT '
ft. ft.
4. Date Well(s)Completed: 5/1/2024 Well ID ft. 1
D
ft. ft
5a. Well Location: 20.D if necessary) i
List all applicable well construction pertmits(ie County,State,Variance,etc 'FROM TO DESCRIPTION(cola-,hardness,soil/rock type,gain size,etc)
MEGAN SELBY Oft. 31 ft. Brown Medium Slate
Facility/Owner Name Facility ID(if applicable) 31 ft 54 ft. Gray Hard Granite Set Casing
17356 HWY 64 WEST MURPHY 28906 Lot 54 ft 59 ft Gray Hard Granite
Physical Address,City,and Zip 59 it 60 ft. Gray Fractured Granite Small Fracture 12 GPM
Cherokee 452000122842000 60 ft. 142 ft. Gray Hard Granite
County Parcel Identification No.(PIN) 142ft 143 ft. Gray Fractured Grande Small Fracture 8 GPM
Sb. Latitude and Longitude degrees/minutes/seconds or decimal degrees: 143 ft 205 ft. Gray Hard Granite
(If well field,one Iat/long is sufficient.) 21.REMARKS
35.016111 N -84.275713 W BIT SIZE-6.00"
6. Is(are)the well(s): Permanent -__-_--
22. Certification:,
7. Is this a repair to an existing well: No 5/3/2024
If this is a repair,fill out known well construction information and explain the nature of the Signature of Certified ell Contactor Date
repair under#2/remarks section or on the back of this form. By signing this form,I hereby certijk that the well(s)was(were)constructed in accordance
with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
8. Number of wells constructed: 1 copy of this record has heen provided to the well owner.
For multiple injection or non-water wells ONLY with the same construction,you can 23. Site diagram or additional well details:
submit one form. You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: 205 (IL)
For multiple wells list all depths if different(example-3(200'and 2(t t 1009 SUMTTTAL INSTRUCTIONS
10.Static water level below top of casing: 30 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
If water level is above casing,use"+" constriction to the following:
Division of Water Quality,Information Procession Unit,
11. Borehole diameter: 6 (to.) 1617 Mail Service Center,Raleigh,NC 27699-1617
12. Well construction method: Rotary 24b.For Injection Wells: In addtion to sending the form to the address in 24a
(i.e.auger,rotary,cable,direct push,etc.) above,also submit a copy of this form within 30 days of completion of well
construction to the following:
FOR WATER SUPPLY WEI.I R ONLY: Division of Water Quality,Undergroun Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a. Yield(gpm): 20 Method of test: Air 24c.For Water Supply Injection Wells: In addtionto sending the form to
the address(es)above,also submit one copy of this form within 30 days of
13b. Disinfection type: HTH Amount: 100 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina DeoMtcent of Environment and Natural Resources -Division of Water Oualitv Revised Jan 2013